Manfred Bergener, Ursula Lehr, Erich Lang and Reinhard SchmitzScherzer, eds. 1983 Aging in the Eighties and Beyond: Highlights of the Twelfth International Congress of Gerontology. New York: Springer Publishing Co. 401 pp., $43.00. Virginia C. Little 1982 Open Care for the Aging: Comparative International Approaches. New York: Springer Publishing Co. 132 pp., S 17.95. Charlotte Nusberg 1984 Innovative Aging Programs Abroad: Implications for the United States. Westport, Conn.: Greenwood Press. 260 pp., $35.00. Hans T h o m a e and George Maddox, eds. 1982 New Perspectives on Old Age: A Message to Decision Makers. New York: Springer Publishing Co. 146 pp., $24.50. The increasing number and proportion of older adults is a worldwide phenomenon. Since the turn of the century many developed nations have experienced an increase in life expectancy at birth that exceeds that witnessed during all of previously recorded history. As we approach the beginning of the next century, the average number of years lived is expected to increase even further. In addition, largely due to lower birth rates, the proportion of older adults is also on the rise. By the middle of the twenty-first century it is expected that one in five persons in the United States will be over 6 5. In all nations the most rapidly growing population category is that of persons over 80 years of age. In 1900, 4% of U.S. elderly were 85 or older. Nearly 25% of the nation's elderly are expected to be over four score years and five by the middle of the next century. So many individuals surviving to such a late age is a major accomplishment of our time. Such incrases promise significant impacts on the individual, the family, society and its entire system of supportive services. However, since the individual faces a lengthy post-retirement period, health status, meaningful existence, and overall quality of life during this extended period must be more completely evaluated. For society as a whole, methods by which the challenges of the changing demographic profile are met must be weighed. A m o n g the most significant challenges are the economic costs of retirement and its impact on the solvency of pension and social security programs. Social security benefits will continue to be the largest single
Journal of Cross-CulturalGerontology I (1986) 429--436. © 1986 by D. Reidel Publishing Company.
source of income for the majority of elderly persons in the U.S., with income from pensions and assets becoming more important for those elderly in higher income groups. It is speculated that when the first of the so-called baby-boom generation turns 65 after the year 2010, the old-age dependency ratio may present a problem for the Social Security system. As a result of increased life expectancy and the trend toward early retirement along with a shrinking supply of entry level workers, the dependent population will grow at a more rapid rate than the working age population. Another major challenge of the geriatric imperative will be balancing quality, access and cost of health care in light of needs. Health care costs are taking more of our national income and more money from the pockets of older adults. It has been established that the majority of health care expenses occur, regardless of age, during the two-year period prior to death. That the majority of persons who die are elderly accounts for much of their representation in the overall health expenses. The availability of long term care services represents still another challenge of the aging U.S. population. Although the U.S. approach to long term care has been medically and institutionally oriented via the focus of the Medicare and Medicaid programs, long term care means so much more. It refers to a continuum of related health and social services, encompassing institutional and non-institutional settings, that serve to provide choices for the chronically ill allowing them to live as independently as possible. The majority of non-institutional support is presently provided by the family of the older adult. For those who live alone or have no nearby next of kin more formal community services may be utilized. However, public funding for such services is limited. Funding, consequently, carries an incentive to institutionalize. Even though efforts are recently underway to provide alternatives, many elderly are in nursing homes receiving higher levels of care than are required. Although ninety-five percent of America's elderly are not in nursing homes the chance of going to one increases for the very old and the very poor. In the future, continued family support promises to be strained due to a number of factors including decreasing family size and the increasing number of older persons living alone. For future cohorts of elderly there will be fewer children to provide assistance. The reduced numbers and changing role of adult daughters, the traditional family caregivers, also promises to be felt. More women are in the workforce outside of the home and may be increasingly unavailable to provide care. Likewise, the very old, those persons most likely to need assistance, will be the fastest growing group. Younger and middle-aged adult children may have more than one generation of older relatives to be concerned about. In addition, caregivers will be aging. The very old may be assisted by an adult child
who is himself/herself listed among the ranks of the elderly. It may be physically and psychologically taxing for some 70 year old children to provide continued assistance to a ninety year old parent. Thus, the United States faces many challenging questions in planning for the needs of its older citizens. Should individuals stay in the workforce longer? Should there be incentives to discourage the present trend toward early retirement while not penalizing the individual who must retire? How should government and researchers balance the goals of extending the length of life and improving its quality? Should the costs of health care for older adults be dealt with separately from the health care costs of the rest of the country? What should be included in long term care? What are the most appropriate roles for the public and private sector in funding and delivering such care? How will costs be controlled? These are among the many policy questions that must be dealt with. Charlotte Nusberg, author of Innovative Aging Programs Abroad, has delivered an exciting and most welcome addition to the gerontological literature in the belief that background information on what other industrialized countries are doing for their elderly can be of relevance to the United States. European nations have aged somewhat earlier than the United States and demonstrate a demographic profile that won't be realized by this country until well after the turn of the next century. Recognizing that attempts to apply the experiences of other countries can be fraught with risks, she points out that some policy alternatives that are being discussed in the U.S. or applied on a limited basis have been systematically in place for some time elsewhere. That Europeans have been providing support to their elderly, who represent 14 to 15 percent of their population, should be of interest to the U.S. The book was prepared under the auspices of the International Federation on Aging (IFA) and its content is based on background papers prepared for the White House Conference on Aging held in December 1981, in Washington, D.C. Nusberg, editor of the IFA quarterly Ageing International, has pulled together a tremendous amount of information largely obtained from the IFA publication, from participation in regional and international aging conferences, and from what other countries have published concerning gerontological and social welfare matters. Eight of the book's eleven chapters are the work of Nusberg. Chapters on retirement income, employment, flexible retirement, health care, community services, housing, and formalized participation in decision making are presented. In each of these a wealth of comparative material is synthesized and policy implications for the United States are examined. Sheila Peace provides a chapter on mental health and Mary Jo Gibson two chapters, one on family support patterns, policies, and programs and the second on educational opportunities. A final concluding chapter briefly summarizes some major issues and policy concerns.
Time and space limit a comprehensive review of such an informationfilled volume. The author does offer that some countries have been more successful than the United States in reducing poverty and the insecurity that can accompany aging. Nusberg postulates that such achievements have been afforded by the strong role played by government in setting policies and supporting programs. Examples range from the National Health Service of the United Kingdom to private loans for housing renovation that are supported in France. In the various European countries government is not viewed as an enemy. Support of the '~¢elfare state" is largely welcomed. Achievements in support of the elderly have been a part of a trend in providing services according to need rather than income. Public universal systems of service have been the norm rather than programs that target specific age groups. No country is without its problems, however, and all are faced with meeting the continuing challenges of their aging populations. If the period of recession worsens, the "welfare state" may be imperiled. To date, existing benefits for the older adult have remained relatively intact. Limited or delayed extension of benefits, rather than cuts, have been the rule during times of economic hardship. For the first time, older persons in some nations have been requested to contribute money toward their health insurance premiums. If economic hard times continue, higher out of pocket payments and/or the limitation of public supported services to the most needy may become a reality. Nusburg cautions that selectivity in service provision may undermine the political support that has allowed a much higher tax rate than Americans are accustomed to. High rates of taxation have sustained the universal service systems. Nusberg states that the policies of the less individualistic European nations have been based on the assumption that universally available programs are more politically viable. Attitudes toward taxation may be enhanced if the population footing the bill realizes that they may be benefited by broad based provisions rather than excluded due to narrowly focused programs. Accessibility, quality and cost control assumptions have been a part of such programs as well. Many believe that a uniform system carries the potential for a greater understanding of how the system works. Consequently persons are not forced to sift through multiple, fragmented programs, do not become intimidated, and do not increase the ranks of those going with unmet needs. Likewise, it is believed that universally available programs are more likely to be of higher quality than are programs which serve only certain groups such as the poor or elderly. Finally, it is maintained by many that quality health and social services are incompatible with profit making ventures. The authors recognize that actions taken in the United States may also
serve as examples to other countries around the world. The U.S. has taken the lead among western nations in raising the age at which compulsory retirement could be imposed for the majority of employees and in encouraging pre-retirement planning and increased educational opportunities for older adults. Education may not only provide stimulating activity, but it may enhance possibilities for continuation in the workplace. Gerontology may be regarded as one of the most multidisciplinary of fields. This situation is exemplified by reviewing the contents of Aging in the Eighties and Beyond edited by Bergener, Lehr, Lang and SchmitzScherzer. Part I introduces the need for an international and interdisciplinary perspective while recognizing that as knowledge accumulates, there seems to be a tendency for increasing specialization at the expense of information exchange between disciplines. This section goes on to provide a regional overview of gerontology in Europe, North America, AsiaOceania, and Latin America. Part II houses thirteen articles dealing with the biology of aging and geriatric medicine. Immunologic aspects of aging, longevity and particular clinical concerns such as drug therapy, cardiovascular disease, geriatric psychiatry and day hospital care are among the topics presented. The eleven articles found in Part III are devoted to behavioral and social science issues includeing stress and coping in old age, intergenerational conflict and cooperation, human sexuality, retirement policy, cost benefits, and social services and support for caregivers of the elderly. Part IV concludes the work by examining future issues and programs for the aged in both developed and developing countries. This most ambitious format represents a collection of "highlights" from material presented at the XII International Congress of Gerontology held in Hamburg, West Germany in 1981. The aim of this association is to promote gerontological research in biology, medicine, and the social sciences and to promote cooperation between these sciences. The thirtyone articles presented in this volume illustrate those aims. Contributions from many nations result in an interdisciplinary, yet highly readable, publication. Concise chapters synthesize the fundamental issues, ideas, and findings of the various symposia which constituted the Congress. For the first time material on aging in developing countries was a principal topic at an International Congress of Gerontology. A chapter by Schade and Apt summarizes the general situation for older persons living in societies undergoing transition from traditional to modern structures. By the year 2000 the elderly will comprise 6 to 8% of the people living in these areas as compared with 20% in the developed nations. This proportion will represent a dramatic increase of 130 to 160%, however, in contrast to the 20% or more growth expected in the developed world. The apparent "low" proportion should not deceive us into thinking that few elderly exist in the Third World. Presently, over half of the world's elderly
live in developing countries and three-quarters of the world's older citizens will reside in such areas by the year 2025. The elderly represent a population for which these transitional societies are not prepared. Social insurance and old-age pensions are virtually non-existent. The traditional social structures and family support systems are being eroded by the processes of industrialization and urbanization. These factors translate into economic hardship for the older person. The status of the elderly is viewed as inversely related to the degree of modernization and the rate of social change. In a traditional society where the rate of social change is slow the elderly hold a place of honor. They are repositories of knowledge and experience and the holders of family property. They can thus move from a productive, independent adulthood to a less active and eventually dependent old age passing on their knowledge, skills and property to their family in return for continued support. Urbanization and migration are changing the family support structure. As young people go to the city they may leave their aged parents behind. If the older person accompanies them, he/she will be moving to an alien environment and may come to represent an economic drain. His/her skills and knowledge will seem unimportant and outmoded in the rapidly changing new environment. Families struggling to support the nuclear unit may not be able to provide for parents as well. The picture for the older adult is particularly dismal as the developing societies, with 50 percent of their populations under 18 years of age, are very youth-oriented. Available jobs go to the young, as do meager support dollars (if available), in countries attempting to combat social ills at all age levels. It is recognized that variation does exist among developing nations as well as within some countries. For instance, the problems for the rural elderly are not yet so severe as they are for those living in cities. New Perspectives on Old Age: A Message to Decision Makers edited by Thomae and Maddox is another very useful compilation of interdisciplinary and international data on aging. It represents an attempt by the International Association of Gerontology (lAG) to summarize meaningful research on aging that might be of assistance to decision makers. The work contained in this volume was prepared in anticipation of the World Assembly on Aging called by the United Nations to convene in the summer of 1982. An overview of the volume is contained in Part I. Part II devotes itself to issues in health and biological aging as well as in behavioral and social sciences. The scarcity of both basic and applied research in the developed world is underscored. It is noted that even if finances were available, their responsible allocation could not be realized. It is lamented that at present assumptions are made with insufficient empirical bases and that findings
relevant to developed countries might be uncritically transferred. Part III presents much information pertaining to public health and social welfare. In Open Care for the Aging: Comparative International Approaches, Little overviews care to the elderly in four societies. In so doing she draws heavily upon data from her own travels and periods of residence abroad. She reminds us that aging may not always present a problem for the individual, in spite of the fact that the aging of populations does constitute a social problem for both developed and developing nations. Little points out that there has been scant attention paid to the specific service requirements of the elderly. The acute-care medical model predominates, inappropriate as it, is, for the long-term needs of the chronically afflicted. She examines open, closed, and unorganized care as three major components of a care system. Open care is community based, designed to. maintain living in one's own home and to forestall premature institutionalization. Closed care refers to institutional care in either medical or boarding facilities. Here daily routines are administratively scheduled and enforced. Unorganized care designates informal supports including family and friends. Open and closed care are viewed as substitutes for informal, unorganized support. In Chapter 3, Little attempts to develop a conceptual framework for the later study of eldercare in four separate societies. She notes that unorganized, open, and closed care coexist and asks what trends concerning their mix can be discerned in developed and developing countries. Unfortunately, although some additional interesting concepts are introduced, they are poorly defined and not at all developed. The reader leaves this chapter unclear as to which of the various possible organizational frameworks introduced will be applied to the international comparisons that follow. Two of the societies examined, Western Samoa and Hong Kong, are presented as examples of developing areas. The remaining two, Japan and Sweden, represent developed nations. Chapters on these societies are largely descriptive and contain some very interesting material. They contribute to the body of literature on aging in international perspective. Likewise, the concluding chapters which focus on issues and problems in open care represent important reading for planners, administrators and providers of services. These final chapters which include material on family caregiving, needs assessment, and the development of service systems stand as discrete units. They do not discuss such issues as they relate to the four societies previously presented. Comparative service delivery to the elderly is a developing field of study that promises to be valuable to gerontological educators and service planners, administrators, and providers around the world. Lessons and ideas learned from other settings (successes and failures) may be useful to those involved in service development, reform, delivery, and maintenance.
These four works contribute to the field of comparative gerontology. Three of the books are useful sources of differential perceptions in a variety of problem areas. The fourth book, by Little, provides data on selected geographic and content areas that establish a basis for comparison. All should prove to be valuable resources for those scholars and practitioners who are concerned with the individual and societal implications of our aging populations.
Dept. of Health Promotion and Human Performance University of Toledo 2801 West Bancroft Street Toledo, 0H43606, U.S.A.